Premature Ejaculation

Premature ejaculation (PE) occurs when a man experiences orgasm and expels semen soon after sexual penetration and with minimal penile stimulation. It has also been called early ejaculation,rapid ejaculation,rapid climax,premature climax, and (historically) ejaculation praecox. There is no uniform cut-off defining "premature," but a consensus of experts at the International Society for Sexual Medicine endorsed a definition including "ejaculation which always or nearly always occurs prior to or within about one minute." The international classification of diseases (ICD-10) applies a cut-off of 15 seconds from the beginning of intercourse. Although men with premature ejaculation describe feeling that they have less control over ejaculating, it is not clear if that is true, and many or most average men also report that they wish they could last longer. Men's typical ejaculatory latency is approximately 4–8 minutes. Men with PE often report emotional and relationship distress, and some avoid pursuing sexual relationships because of PE-related embarrassment. Compared with men, women consider PE less of a problem, but several studies show that the condition also causes female partners distress.Premature ejaculation is most prevalent sexual dysfunction in men; however, because of the variability in time required to ejaculate and in partners’ desired duration of sex, exact prevalence rates of PE are difficult to determine. In the “Sex in America” surveys (1999 and 2008), University of Chicago researchers found that between adolescence and age 59, approximately 30% of men reported having experienced PE at least once during the previous 12 months, whereas about 10 percent reported erectile dysfunction (ED). After age 60, ED becomes men’s most prevalent sex problem, however premature ejaculation remains a significant concern affecting 28 percent of men age 65–74, and 22 percent of age 75–85. Other studies report PE prevalence ranging from 3 percent to 41 percent of men over 18, but the great majority estimate a prevalence of 20 to 30 percent—making PE men’s most common sex problem. There is a common misconception that younger men are more likely to suffer premature ejaculation and that its frequency decreases with age. Prevalence studies have indicated, however, that rates of PE are constant across age groups. Mechanism of ejaculation Main article: Ejaculation The physical process of ejaculation requires two actions: emission and expulsion.

The emission is the first phase. It involves deposition fluid from the ampullary vas deferens, seminal vesicles, and prostate gland into the posterior urethra. The second phase is the expulsion phase. It involves closure of bladder neck, followed by the rhythmic contractions of the urethra by pelvic-perineal and bulbospongiosus muscle, and intermittent relaxation of external urethral sphincters. Sympathetic motor neurons control the emission phase of ejaculation reflex, and expulsion phase is executed by somatic and autonomic motor neurons. These motor neurons are located in the thoracolumbar and lumbosacral spinal cord and are activated in a coordinated manner when sufficient sensory input to reach the ejaculatory threshold has entered the central nervous system. Intromission time The 1948 Kinsey Report suggested that three quarters of men ejaculate within two minutes of penetration in over half of their sexual encounters. Current evidence supports an average intravaginal ejaculation latency time (IELT) of six and a half minutes in 18–30 year olds. If the disorder is defined as an IELT percentile below 2.5, then premature ejaculation could be suggested by an IELT of less than about 2 minutes. Nevertheless, it is possible that men with abnormally low IELTs could be "happy" with their performance and do not report a lack of control. Likewise, those with higher IELTs may consider themselves premature ejaculators, suffer from detrimental side effects normally associated with premature ejaculation, and even benefit from treatment. Diagnostic issues When deciding the appropriate treatment, it is important for physician to distinguish PE as a "complaint" versus PE as a "syndrome". About 20 years ago, PE was classified into "lifelong PE" and "acquired PE". Recently, a new classification of PE was proposed based on controlled clinical and epidemiological stopwatch studies and it included 2 other PE syndromes: "natural variable PE" and "premature-like ejaculatory dysfunction". Only individuals with lifelong PE with IELT shorter than 1–1.5 minutes should require medication as a first option, along with or without therapy. For those who fall into one of the other categories, treatment should consist of patient reassurance, behavior therapy, and/or psychoeducation to explain irregular early ejaculation is a normal variation. Several possible subclassifications have been discussed, but none is in universal usage. Primary premature ejaculation refers to lifelong experience of the problem (since puberty), and secondary premature ejaculation reference to the problem beginning later in life. It has also been subdivided into global premature ejaculation, when it occurs with all partners and contexts, and situational premature ejaculation, when it occurs in some situations or with specific partners. Causes The causes of premature ejaculation are unclear. Many theories have been suggested, including that PE was the result of masturbating quickly during adolescence to avoid being caught by an adult, of performance anxiety, of an unresolved Oedipal conflict, of passive-aggressiveness, and having too little sex—but there is little evidence to support any of these theories. Several physiological mechanisms have been hypothesized to contribute to causing premature ejaculation including serotonin receptors, a genetic predisposition, elevated penile sensitivity, and nerve conduction atypicalities. The nucleus paragigantocellularis of the brain has been identified as involved in ejaculatory control. Scientists have long suspected a genetic link to certain forms of premature ejaculation. In one study, ninety-one percent of men who have had premature ejaculation for their entire lives also had a first-relative with lifelong premature ejaculation. Other researchers have noted that men who have premature ejaculation have a faster neurological response in the pelvic muscles. PE may be caused by prostatitis or as a drug side effect. Treatments

Several treatments have been tested for treating premature ejaculation. A combination of medication and non-medication treatments is often the most effective method. Self-treatment

Many men attempt to treat themselves for premature ejaculation by trying to distract themselves, such as by trying to focus their attention away from the sexual stimulation. There is little evidence to indicate that it is effective, however. Other self-treatments include thrusting more slowly, withdrawing the penis altogether, purposefully ejaculating before sexual intercourse, and using more than one condom. Some men report these to have been helpful. By the 21st century, most men with premature ejaculation could cure themselves, either solo or with a partner, using self-help resources, and only those with unusually severe problems had to consult sex therapists, who cured 75 to 80 percent. Psychoanalysis Freudian theory postulated that rapid ejaculation was a symptom of underlying neurosis. The man suffers unconscious hostility toward women, so he ejaculates rapidly, which satisfies him but frustrates his lover, who is unlikely to experience orgasm that quickly. Freudians claimed that premature ejaculation could be cured using psychoanalysis. But even years of psychoanalysis accomplished little, if anything, in curing premature ejaculation. There is no evidence that men with premature ejaculation harbor unusual hostility toward women, however. Sex therapy Several techniques have been developed and applied by sex therapists, including Kegel exercises (to strengthen the muscles of the pelvic floor) and Masters and Johnson's "stop-start technique" (to desensitize the man's responses) and "squeeze technique" (to reduce excessive arousal) To treat premature ejaculation, Masters and Johnson developed the “squeeze technique.” Men were instructed to pay close attention to their arousal pattern and learn to recognize how they felt shortly before their “point of no return,” the moment ejaculation felt imminent and inevitable. Sensing the point of no return, they were to signal the partner, who squeezed the head of the penis between thumb and index finger, suppressing the ejaculatory reflex and allowing the man to last longer. The squeeze technique worked, but many couples found it cumbersome. From the 1970s to the 1990s, sex therapists refined the Masters and Johnson approach, largely abandoning the squeeze technique and basing the program on a simpler and more effective technique, “stop-start.” During intercourse, as the man senses he’s approaching his point of no return, both lovers stop moving and remain still until the man’s feelings of ejaculatory inevitability subside, at which point, they are free to resume active intercourse. In addition to the stop-start technique, other sexual adjustments help men develop and maintain ejaculatory control, among them: masturbation exercises, deep breathing, and whole-body massage. Sex therapists estimate that the refined last-longer program teaches effective ejaculatory control to 90 percent of men. The authors of one study concluded that sex therapy “has a remarkable therapeutic effect on premature ejaculation.”Medications Drugs that increase serotonin signalling in the brain slow ejaculation and have been used successfully to treat PI. These include selective serotonin reuptake inhibitors (SSRIs), such as paroxetine (Paxil), sertraline (Zoloft), and fluoxetine (Prozac), as well as clomipramine (Anafranil). Ejaculatory delay typically begins within a week of beginning medication. The treatments increase the ejaculatory delay to 6–20 times greater than before medication. Although men often report satisfaction with treatment by medication, many men discontinue it within a year.Dapoxetine (Priligy) is a short-acting SSRI marketed for the treatment of premature ejaculation. Dapoxetine is the only drug with regulatory approval for such an indication. Currently, it is approved in several European countries, including Finland, Sweden, Portugal, Austria and Germany. Dapoxetine is currently waiting for U.S. Food and Drug Administration (FDA) approval after concluding the Phase III study, which included participants from 25 other countries, including the United States. In this diverse population, dapoxetine significantly improved all aspects of PE and was generally well tolerated. Paroxetine (Paxil) appears to be the most effective drug treatment. In a 6-week long randomized, double-blind study, the ejaculatory latency of men with PE increased from an average 20 seconds to 2-1/2 minutes, whereas there as no change at all in the placebo group. Tramadol (Ultram or Tramal) is an FDA-approved atypical oral analgesic generally used to treat mild pain. Tramadol also has few side effects, low abuse potential, and increases ejaculatory latency to 4-20 times in more than 90% of men tested. Clomipramine (Anafranil) is sometimes prescribed to treat PE. One side effect of the drug can help delay ejaculatory response. The side effect is described by the Mayo Clinic as "Increased sexual ability, desire, drive, or performance. Desensitizing topical medications that are applied to the tip and shaft of the penis can also be used. These are applied "as needed," 10–15 minutes before sexual activity and have fewer potential systemic side effects as compared to pills. Use of topicals has is sometimes disliked due to the reduction of sensation in the penis as well as for the partner (due to the medication rubbing onto the partner). These effects can be lesser with topical anesthetic sprays History Ejaculatory control issues have been documented for more than 1,500 years. The Kamasutra, the 4th century Indian sex handbook, declares: “Women love the man whose sexual energy lasts a long time, but they resent a man whose energy ends quickly because he stops before they reach a climax. Nineteenth-century authorities considered rapid ejaculation a sign of masculine vigor. Non-human mammals ejaculate quickly during intercourse, prompting biologists to declare that rapid ejaculation had evolved into men’s genetic makeup to increase their chances of passing their genes.

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